This report describes a series of symptomatic patients with obstructive hypertrophic cardiomyopathy with significant postprandial hemodynamic changes. This finding was identified by history, clinical examination, and echocardiography in 6 consecutive symptomatic patients referred for the evaluation of ventricular septal reduction therapy. Counseling these patients with dietary changes to include small frequent meals and to increase noncaffeinated fluid intake resulted in reductions in symptoms. In conclusion, severe symptoms in obstructive hypertrophic cardiomyopathy unresponsive to pharmacologic treatment frequently result in referral for definitive septal reduction therapy through surgery or, less frequently, alcohol septal ablation therapy. However, recognition of postprandial exacerbation in symptomatic patients may allow for nonpharmacologic dietary interventions that may obviate the need for more invasive therapies and their associated complications.
Our group recently described a series of patients with hypertrophic cardiomyopathy (HC) referred for septal reduction therapy because of severe symptoms with incomplete response to pharmacologic therapy. These patients had a concomitant diagnosis of significant obstructive sleep apnea (OSA). With control of the underlying sleep disorder, the patients had reductions in left ventricular (LV) outflow tract (LVOT) obstructions, and septal reduction therapy was deferred. We now present a series of patients with HC with severe LVOT obstructions and postprandial symptoms who also benefited from nonpharmacologic and noninvasive therapy.
Methods
Patients were recruited from the HC outpatient clinic. Typically, patients undergo same-day echocardiography before the scheduled clinic appointment. Six patients with divergent physical examination and echocardiographic findings were investigated. It has been our routine practice to assess patients’ hydration and meal status at the time of initial echocardiography and to repeat limited hemodynamic echocardiography either after a meal or after fasting for a few hours. This practice led to the identification of these patients, who demonstrated profound provocable LVOT gradients after meals ( Figure 1 , Table 1 ). There was no significant change in systolic or diastolic blood pressure, and a 9 beat/min increase in heart rate was noted postprandially compared to the baseline assessment (p = 0.05). Patient medications are listed in Table 2 ; of note, each patient was taking a β blocker, while only 1 patient each was taking a calcium channel blocker, angiotensin-converting enzyme inhibitor, and disopyramide.
| Patient | Age (years) | Gender | Time Interval Between Fasting and Postprandial Echocardiography (hours) | Fasting BP (mm Hg) | Postprandial BP (mm Hg) | Fasting HR (beats/min) | Postprandial HR (beats/min) | Rest LVOT Peak Gradient (mm Hg) | Postprandial LVOT Peak Gradient (mm Hg) |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 63 | M | 2 | 120/60 | 140/60 | 61 | 80 | 58 | 100 |
| 2 | 70 | M | 2.5 | 140/80 | 136/76 | 50 | 67 | 19 | 100 |
| 3 | 69 | M | 4 | 120/60 | 108/70 | 51 | 55 | 25 | 81 |
| 4 | 64 | M | 2 | 146/80 | 146/80 | 72 | 69 | 31 | 92 |
| 5 | 75 | F | 1.5 | 158/60 | 148/58 | 48 | 63 | 50 | 192 |
| 6 | 68 | M | 2 | 140/62 | 135/80 | 52 | 56 | 35 | 71 |
| Patient | BB | CCB | ACE Inhibitor/ARB | Disopyramide | Statin |
|---|---|---|---|---|---|
| 1 | Yes | No | Yes | No | Yes |
| 2 | Yes | Yes | No | No | Yes |
| 3 | Yes | No | No | No | Yes |
| 4 | Yes | No | No | No | Yes |
| 5 | Yes | No | No | No | No |
| 6 | Yes | No | No | Yes ⁎ | Yes |
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